16 November 2009

The patient's mother was livid. "What do you mean you're not going to give my kid Tamiflu? You just said he had influenza, didn't you?"

I sighed, and squared my shoulders just a bit more, "Yes, while I'm almost certain this is influenza, we're not treating routinely with Tamiflu. It only shortens the duration of illness by a very small time, less than a day. And for healthy kids like yours, it does not seem necessary for prevention of any of the complications of influenza."

"But I was here last week with his brother," she retorted, "and we saw Dr Feelgood, and he said that it was essential that we start the treatment immediately!"

"It is true that if you are going to treat with antivirals that you need to start within the first twenty-four hours. The CDC, however, has released guidelines regarding which patients need to be treated. For children, that is primarily those under two years of age and those with co-existing conditions like asthma which predispose them to complications. Again, little Billy here is seven and perfectly healthy, so he does not require the medication."

"Then why did Dr Feelgood prescribe it for his brother? He's healthy, too, but he got the medicine, and he got better faster because of it."

"I really shouldn't say why Dr Feelgood did what he did, because I haven't seen your other child. But the CDC is not recommending routine antiviral treatment of healthy schoolchildren."

"So what am I supposed to do? Just let him suffer? You didn't even do a test! How do you know it's influenza? Dr Feelgood at least tested him! You're not doing anything!"

"I haven't been doing the tests since they have proven rather inaccurate. In short, if I test Billy and the test is negative, I'm not going to believe it because his symptoms are so classic for influenza and he has a brother with the flu. So if you are not going to believe the test result, and if it's not going to change your management, why do the test?"

She started gathering her things. "I just can't believe this. You are doing nothing for my son, who is clearly desperately ill. You're the worst doctor I've ever seen and I am never coming back here. This whole thing has been a huge waste of time. Why did I even come in here if you weren't going to help us?"

"You could have called his pediatrician, you know," I added, "seeing that it's a Monday morning. I'm sure they would have made time to see him."

"He would have given us the Tamiflu, too!" she shot back.He probably would have, I thought to myself as I went back to the nursing station and picked up the next chart. It was a whole family checking in because they were exposed to the flu, and they wanted Tamiflu prophylaxis. Seems their neighbors had been exposed, and Dr Feelgood had given the whole family prescriptions.

Note to self: next time I see Dr Feelgood, I'm going to kick his ass so hard his prostate's going to get impacted in his esophagus.

Only problem is that there isn't just one Dr Feelgood. I'm surrounded by them. In the ER, in the primary care offices, and (especially) in the urgent care centers. I understand why docs do it: you see a patient who looks absolutely miserable, and you want to do something for them. You want to make them better. And there's a drug for this! It's even got "flu" right in the name! So you know it's gotta do something! Right? It's the hardest thing in the world for a doctor to do when you see someone legitimately ill: to put your hands in your pockets and back slowly away from the patient. I'm not immune. I confess: in moments of weakness I have written a couple of Tamiflu prescriptions that were not indicated, just because I felt bad for the patients.

Still, it's maddening to see how many docs are out there flaunting the guidelines. Patients talk to one another, they see the inconsistencies in treatment, and they get mad. And the docs who are doing the right thing and following the best practices are the ones that get grief over it. It really ticks me off.

And I don't even want to look at my Press-Ganey numbers for this quarter.

As a patient, I prefer working with physicians who don't reflexively prescribe. I've got GERD, and while drugs certainly helped heal the chronic gastritis, the straight talk ("take off twenty or thirty pounds, move your body more, and drink more water") was more helpful, if not the quick fix I hoped for.

Medicine - well, diagnostics, anyhow - is an art, not a science, and if a patient can't accept some variability in treatment b

I feel like I have the exact same conversation you quoted... but I have a secret weapon. I've started to quote the study that was in Annals regarding the potential psychiatric side effects of Tamiflu in little kiddos. And that even though this medicine helps a little, it has side effects, too. Most parents agree to skip it at that point.(Study was done in Japan, and might have been a few months ago, as I'm a wee bit behind in my journal-reading.)

That mother comes from the generation of parents that think they are being judged or graded at all times. They think that if their kiddos aren't perfect; it's a direct indictment against their parenting style. If she wanted meds; why didn't you give her that new med "Tylenol"? For some reason this generation of parents can't seem to bring themselves to use some of those "old" meds. Everything has to be the new, improved product.Cripes, I remember when I was a kid, my mom would dissolve an ASPIRIN in a tsp of water and make me take it. That and forcing me to drink juice and to just sleep on the couch was 'bout all we had!

Yeah, well, send 'em to me and I won't give 'em tamiflu either. Above poster is correct about the risk of hallucinations, confusion, agitation. Tell parents about that and the vomiting and diarrhea and usually they get off your back.Sorry you had to deal with that. Can't cure stupid, even if you're a great doc.~your child's pediatrician

yep. i practice the way you do and some patients just refuse to be educated. it's very tempting to give them what they want, which is how dr feelgood practices. tamiflu, z-pak, vicodin. you know, the "go away" prescription.

oh, and get rid of press ganey. i'm sure your department has more pressing needs you could spend that money on.

Anon 7:55 is right...if your kid doesn't see the doctor, and/or get some pill or test for every illness (Tylenol/ibuprofen doesn't count) or doesn't have some planned activity every day of the week, you're a bad parent. Other bad parent signs include not volunteering enough for school events, having your kid not be the best in the parent's chosen sport, and, for smaller kids, not enrolling them in the best preschool in town.

My favorite quote this week: "So, you won't test him for flu? You just want us to take him home and leave him there, alone, to die?" No-- I want you to do all of the agressive treatments that usually help for viral infections: fluids, rest, fluids, antipyretics, rest and fluids. I see you haven't tried any of those yet.

I will often make some snarky remark like "I'm not sure why Dr. Feelgood would risk giving your other son all the side effects from this expensive medication when all published guidelines show that it will have little if any effect on his outcome. I'll have to talk to him about it next time I see him." As for the flu test, with nutjobs like this, I just do it. If the test is negative, then you can tell mom that the test shows the kid doesn't have the flu. End of argument.

That mother comes from the generation of parents that think they are being judged or graded at all times.

Or... and just spit-balling here... she responsibly took her other son to the ER (perhaps the kid was in bad shape and it was on a Friday evening) and was told by the physician there that she was in the ER appropriately and the correct treatment was Tamiflu.

So now she has a second kid with a similar situation and she does the thing she did last time. A different result for what to her looks like the same condition is confusing and scary.

Sure, she's not a board-certified ER doctor, so she should know the difference between the two conditions to the granularity such that she can, given the literature she should be reading, make the same responsible decision her doctors are making. I guess it sounds like she lost her temper in a minor way, but without knowing what her other circumstances are, it's a little premature to decide she's a moron for being upset when her two kids got totally different treatments for the same illness.

You have hit the nail on the head. I knew when I posted this that my real point was going to get lost in the patient side of the story. But I was too lazy to rewrite it. I'm not upset at the patient/mom so much as at the docs who ignore standards and create the perceived differential in treatment. 'Course, it was the mom who got mad and yelled (in my quasi-fictional vignette) so she looks like the unreasonable person, when in fact the problem in this scenario is with Dr Feelgood.

lol, being a pcp I would of giving him the tamiflu. So what. I need my patients to come back. People do not care about the CDC or anyone elses recommendations. They care only about their little Joey and only know what's in the room. A sick kid. I don't lecture people. Bad for business and I only have 15 mins so I can stay out of the red. Sad but true.

On a side note:If health care reform truely happens then maybe all the pay-for-procedure crap will change as well and shift money to primary care prevention. Then I can spent more time with patients then thinking if I have enough procedures today to make my M5 payment.

last anonymous poster, what a cop-out. I'm a PCP, my production is fine, I am busy as sh*t, and I can take the time to do what is right for my patients, even if that means explaining why tamiflu (or antibiotics, or pain meds or all the other crap people think they want) is not appropriate.If you have any bedside manner it works fine, and it is irresponsible not to.~Shadowfax' child's pediatrician

I read and post at a message board full of mothers and I was shocked at how many took their children in with the flu for Tamiflu. We just holed up at home with our Tyenol/Motrin and drank a lot of fluids.

Now the broken collar bone we dealt with last April earned us a trip to the ER for seven year old girl child, but rarely does the flu give reason for even a visit to the doctors office.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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